Archive for the ‘Improving Patient Services’ Category
Friday, July 15th, 2011
On June 20, Kaiser Health News published an article jointly with The Washington Post, in which it reported the lack of progress in reducing wrong-side and wrong-site surgeries since 2004, when Dr. Dennis O’Leary (then president of the Joint Commission) commented on this critical issue. According to this article, wrong-side and wrong-site surgeries may have actually increased rather than decreased. According to Kaiser Health News, 93 cases were reported to the Joint Commission as compared to 49 cases in 2004. Reporting such incidents to the Joint Commission is voluntary and the article did not specify whether this incidence increase was due to a true increase in wrong-side and wrong-site surgeries, or whether it was also caused by a steady increase in voluntary reports by physicians and hospitals.
On June 28, the Robert Wood Johnson Foundation announced the launch of yet another website to help patients find information about the cost and quality of local healthcare. While the number of websites aimed at helping patients decide where to go for their care continues to increase, it does signify the increasing thirst for good information about where to go for the best care.
What both articles, in addition to many others, indicate is that we still know so little about the quality and safety of healthcare in general and cancer care in particular. I have commented on the lack of transparency a number of times in previous blogs, so I hope that you will indulge me once again as I share my thoughts on the importance of transparency for cancer centers from a different point of view.
While reading the two articles and viewing the Volkswagen example of transparency once more, I was reminded of an important insight a professor shared with us during a graduate course in production, as I pursued my Master’s degree in Industrial Engineering and Management Science. During the course, the professor showed us these pictures.
Figure 1. Rocks and Boulders
Figure 1 shows a cross section of a river with rocks and a boulder that prevent ships from passing through. This is metaphor for a process in which the water level represents resources and inventory, the ship represents products, services or patients, and the rocks and boulder represent bottlenecks and waste.
Figure 2. Traditional Approach: More is Better
Figure 2 shows the same cross section of the river with the water level well above that rock, allowing ships to easily pass through. This picture served as a metaphor for how many organizations in the US, Canada and Western Europe tried to improve throughput. They simply increase the “water level” (i.e., increase resources and inventory) to overcome any obstacle. The problem is that the bottlenecks and waste still remain and could pose problems in the future, when resources become limited or demand increases. This strategy is no longer an option for cancer programs in the current economic climate in addition to a rising demand for care and an increasing shortage of oncologists and radiation oncologists.
Figure 3. Toyota’s Approach: Reducing Resources
Figure 3 shows the same cross section of the same river, but this time, the water level is well below the tip of the boulder and more rocks become visible. This is a metaphor for of how Toyota continues to approach its supply chain processes. Toyota continuously “lowers the water level” (i.e., by simplifying, streamlining and standardizing processes) to identify where the rocks and boulders are (i.e., where process bottlenecks are or waste occurs) so they can remove them.
Figure 4. The Result of Toyota’s Approach
Figure 4 finally shows that by removing rocks and boulders (bottlenecks and waste), the ship (products, services or patients) can still sail easily on the river without needing a high water level (resources and inventory).
Western companies, having had access to ample capital, land, raw materials and labor, simply eliminated any obstacles to production (flow and quality) by “flooding” the supply chain process with capacity and inventory. Toyota, on the other hand, had only limited access to capital, land and raw materials so it made a virtue out of necessity. By tightly managing its resources, it forced obstacles (a.k.a. process bottlenecks and waste) to become obvious and, thus, make it much easier to identify and eliminate them. That is how Toyota became known as the “Machine That Changed The World” and the creator of “Lean”.
So what does this have to do with transparency in cancer care? Well, creating transparency is like lowering the water level in the river to uncover the rocks and boulders. If we continue to ignore quality, safety and inefficiency issues or simply cover them up, we’ll continue to perpetuate the current problems. And we will never learn about our own processes, improve them and grow as a successful learning and adaptive organization should.
I am personally somewhat skeptical of requiring cancer programs to report each and every error to the government or an accreditation agency. It often leads to reporting a minimal and politically acceptable set of indicators. There is still little proof that such reporting requirements actually improve the quality and safety of health care in a significant way. The aforementioned articles suggest that significant improvements have not materialized.
Rather than viewing transparency as a necessary evil to satisfy some external agency, cancer programs should embrace transparency as a powerful tool to transform their care programs and to differentiate themselves in a compelling manner from competing programs in their region. Cancer programs that successfully transform and become safe, lean and agile should proudly share their successes with the general public. By proudly sharing the results of improvement efforts with the general public, cancer programs stand out for their excellence in caring for cancer patients.
Organizations that continue to transform their care delivery systems by increasing internal and external transparency, e.g., Geisinger Health System, Johns Hopkins Medicine, the Mayo Clinic, ThedaCare, the Virginia Mason Medical Center, etc., have demonstrated that internal drive, rather than external pressure, leads to impressive results. Toyota learned to do this over half a century ago.
So, how much do you really know about the quality, safety and efficiency of your cancer program? Do you know where all the “rocks and boulders” are in your cancer program?
Call us if you wish to learn more about those “rocks and boulders” in your cancer program.
Yours in oncology excellence,
Paul Schilstra
President
If you have any questions, contact primeASCENT by calling 410-444-6024 or click here today!
Check us out on Facebook, LinkedIn and Twitter as well!
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Friday, July 1st, 2011
Last Tuesday, the Department of Health & Human Services (“HHS”) canceled its plans for deploying “mystery shoppers”. The goal of this planned initiative was to determine the impact of the growing shortage of primary care physicians, as well as the type of insurance coverage, on the timely access to primary care. The recent announcement by HHS to introduce “mystery shoppers” was met with a great concern on the part of the primary care physician community, as was described in the New York Times article “U.S. Plans Stealth Survey on Access to Doctors” last Sunday. But it was the critical letter from Illinois Senator Mark Kirk to HHS Secretary Kathleen Sebelius that prompted the cancellation of the “mystery shoppers” project. In his letter, Senator Kirk asked a series of challenging questions about the need for and execution of this plan. Shortly after he shared his letter on the Senate floor, HHS announced the cancelation of its plans.
While the use of “mystery shoppers” by government agencies may or may not be questionable, the use of “mystery shoppers” can be a very effective tool for cancer programs to identify issues with timely and easy access to care. As many providers strive to be more patient-centric and improve the patient’s experience, timely and easy access to cancer care can be among the key factors that help a cancer program differentiate itself from competing programs.
Let us consider the results of the recent study published at the Annual Meeting of the American Society of Clinical Oncology by Drs. Keerthi Gogineni and Katrina Armstrong, from the University of Pennsylvania. In this study, volunteers posed as patients with a new diagnosis of inoperable hepatocellular carcinoma. Only 23% of the “patients” were able to get a new patient appointment out of 432 attempts. These results should serve as a wake-up call to cancer programs about potentially avoidable barriers to timely access to cancer care.
According to the study, callers posed as “patients” with varying types of cancer and insurance coverage. The most frequent reason (39%) that the “patients” couldn’t get a first appointment was that both oncology practices and hospitals required that patients have all of their medical records in their possession when they scheduled their first appointment. This, of course, is likely to be an extremely challenging and stressful experience for patients who are already anxious and, perhaps, suffering from pain. Do patients even know how to track down images, lab results and other key parts of their records from different providers at different locations, and furthermore which records are even necessary? In many instances, patients may not understand or fully appreciate what the oncologist(s) need to finalize the diagnosis and determine the best course of treatment.
In addition, other reasons why the “patients” were unable to schedule an appointment included the inability to reach the scheduler (24%), the need to obtain a referral first (18%), the requirement to go through a new-patient coordinator first (3%), or the need to talk to a financial counselor.
This does not exactly paint a patient-friendly picture and may actually hurt a cancer program’s reputation. Having a complete medical picture is critical to the clinical decision-making process, but delaying anxious patients’ access to timely care until they have all of their clinical documentation gathered poses an undue burden on them and will likely tarnish a cancer program’s reputation. There are better and easier ways to address this issue. Such improvements would also ensure that the clinical team has all the critical facts needed to make an informed decision about the best treatment course for the patient.
Let’s also not forget that first impressions matter a great deal, in healthcare as well as in other industries. Schedulers, registration clerks, patient navigators, financial counselors and the folks staffing the parking garage are all part of the team that patients will be interacting with during initial consultations, treatment and follow-up. Their behavior, as well as policies and procedures that guide their behavior, and the layout of the reception and waiting areas, shape a patient’s perception of a cancer program’s level of customer service in a significant way.
So, assessing he accessibility of your cancer program is critical for improving access to your cancer program and improving its efficiency and reputation. By having hospital managers or others pose as “patients”, you will quickly learn about the impact of policies and procedures, the patient’s physical experience, operational inefficiencies and the attitudes and behavior of front-end staff and their impact on the initial patient experience with your cancer program. By creating easy and timely access to your program’s cancer care, you create one more compelling reason for patients to come to your cancer center.
How easy is it for new cancer patients to schedule appointments at your cancer center? When was the last time you reviewed how patients experience the start and end of their interactions with your cancer program? Call us for a free consultation on how primeASCENT can best assist you with improving the overall patient experience.
Yours in Oncology Excellence,
Paul Schilstra
President
If you have any questions, contact primeASCENT by calling 410-444-6024 or click here today!
Check us out on Facebook, LinkedIn and Twitter as well!
Tags: American Society of Clinical Oncology, Appointment, Cancer, Cancer care, cancer center, Cancer program, Care, Department of Health & Human Services, diagnosis, Effective Tool, Efficiency, egistration clerks, financial counselors, Government Agencies, Healthcare, HHS, How Accessible Is Your Cancer Program, Identify Issues, inoperable hepatocellular carcinoma, Insurance Coverage, mystery shoppers, New York Times, Oncology, patient navigators, Patient's Experience, Patient-centric, Patients, Primary Care, primary care physicians, PrimeASCENT, Providers, Senate, Timely Care, U.S. Plans Stealth Survey on Access to Doctors, Wake-up Call
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Friday, June 17th, 2011
Today, I read an article in Internal Medicine News that reported on the struggle of new cancer patients to get appointments. The research was conducted by Dr. Keerthi Gogineni and Dr. Katrina Armstrong of the University of Pennsylvania in Philadelphia. Volunteers posing as new cancer patients were able to secure an appointment only 23% of the time in 432 attempts. The report detailed the barriers that these volunteers faced when trying to schedule an appointment. This news is rather disturbing but is even more troubling in light of the coming cancer tsunami.
The coming wave of cancer patients has three things in common with a real tsunami: speed, size and impact. The facts suggest that a serious problem is approaching rapidly and yet I don’t read many discussions on this topic. Let us take a closer look at this coming cancer tsunami.
- At least one in three people will develop cancer at some point in his or her life, according to the National Cancer Institute, with the probability of developing cancer increasing dramatically with age.
- At the same time, the percent of people over 60 years old will increase by 29% over the next 10 years, while the overall population will increase by almost 10% over the next 10 years, according to the US Census Bureau. These high growth rates will result in a substantial increase in cancer patients and survivors, who will require a mix of services to effectively manage their illness and overcome physical, cognitive and emotional complications during and after treatment.
- In 2014, the Affordable Care Act, if left unchanged, will provide coverage for an estimated 30 million uninsured patients, adding to the sustained surge in cancer patients.
- Overall, cancer patient volumes are expected to grow by 55% by 2020, while the number of physicians is increasing by less than 15% during the same period In addition, the total number of patients undergoing radiation therapy is expected to grow by 22%, while the number of radiation oncologist FTEs is expected to only grow by 2% during that same period.
As the cancer population swells, revenues will continue to decline, regulatory requirements will continue to increase, treatment options will become more abundant, complex and costly, and the need for supportive services will become greater as well.
This is a daunting picture and does beg the question: what can individual cancer programs do to prepare for this significant imbalance between demand on the one side and limited capacity and funding on the other side.
Once again, we can look to other industries for inspiration, including car manufacturers, banks and the airline industry. Here are a few approaches, borrowed from these industries, that may help your cancer program prepare for the cancer tsunami.
- Reduce demand
- Smooth demand
- Implement “Lean”
- Automate appropriate activities
- Increase the role of mid-level providers, pharmacists, nurses and therapists
Reducing demand to reduce pressure on the cancer program is one of the first strategies to consider. Specializing in high volume cancers and referring patients with rare or more complex forms of cancer to other, better equipped cancer programs is one way to reduce demand. Too many smaller, community hospital-based cancer programs admit and treat patients whose cancers are less common and/or more complicated, even though they do not have the expertise, experience and resources to effectively treat these patients. In addition, when patients do not respond to the standard of care, physicians should discuss meaningful end-of-life strategies with the patients. This not only benefits the patient with respect to quality of life but also reduces the demand on the cancer program to provide grueling and costly treatments without reasonable expectations for success. Finally, cancer programs may want to become more active in the prevention of cancer to further reduce demand for care.
The second strategy to reduce pressure on the cancer program is to smooth demand. The demand for cancer-related services usually fluctuates on a daily, weekly, monthly and annual basis. In addition, newly diagnosed patients, current patients, patients with unexpected complications, etc. all have different needs and can easily overwhelm the clinical team if not managed properly. In addition, most outpatient cancer programs operate five days per week and eight hours per day, with the exception of the inpatient units. This greatly reduces the cancer program’s ability to better spread demand for services and also requires patients to undergo treatment during work hours only. Improved scheduling procedures, combined with expanded hours, e.g., seven days per week and up to twelve hours per day, may help reduce the stress on the cancer program. It also has the added advantage of generating more revenues and improving the bottom line.
The application of Lean Six Sigma to eliminate waste, i.e., things that do not provide value from the patients’ point of view, further reduces pressure on the cancer program. By removing non-value-added activities as well as daily hassles for physicians and the clinical team, the care processes become faster, while the patient experience improves and the clinical team will be able to spend more time providing excellent care. I have discussed the examples of Toyota and Volkswagen in previous blogs.
Standardization of care processes, e.g., scheduling, checklists, time-outs, or NCCN clinical guidelines, will also help reduce inefficiencies and the risk for errors. Southwest Airlines is a great example of this. All its airplanes are Boeing 737s so that all its pilots are able to fly any plane on any route. In addition, cancer programs should look into ways to shorten treatment cycles, e.g., by evaluating treatment modalities that require less total treatment time per patient. Hypo fractionation with IMRTand high dose rate brachytherapy are examples of treatment options that enable the application of higher doses of radiation that can be administered in shorter time span.
Healthcare in general is still a labor-intensive industry and understandably so. However, automation through physician order entry, results reporting, electronic medical records, etc., can remove unnecessary hand-offs, shorten the process time and reduce the potential for errors. Banks and the airline industry are great examples of using automation to reduce the need of people for activities that customers can complete themselves. Today, we take ATMs at banks and check-in kiosks at airports for granted.
Finally, cancer programs can help reduce the pressure on physicians by involving other members of the clinical team in care planning, treatment and follow-up with patients. Johns Hopkins Medicine, ThedaCare and Virginia Mason Medical Center all published their experiences with how they increased the roles of nurse practitioners or physician assistants, nurses, pharmacists, therapists and others to better distribute and balance the workload among the clinical team members.
As the cancer population swells and funding becomes scarce, cancer programs across the US need to look for ways to find a good balance between increased demand for services with limited capacity and funding. Cancer programs should be creative and draw from ideas tested and proven in other industries to find this balance.
Call us for a free consultation on how primeASCENT can best assist you in preparing for the coming cancer tsunami.
Yours in Oncology Excellence,
Paul Schilstra
President
If you have any questions, contact primeASCENT by calling 410-444-6024 or click here today!
Check us out on Facebook, LinkedIn and Twitter as well!
Tags: Automate appropriate activities, Cancer, Cancer care, Cancer center Maryland, Cancer Maryland, cancer patients, cancer population, Cancer program, cancer programs, cancer tsunami, Care, checklists, Complex, Complications, Costly, diagnose patients, Efficiency, Efficient, Ellicott City, Example, Health Affairs, Healthcare, high volume cancers, High-Performance, Hospital, Implement “Lean, Increase the role of mid-level providers, Internal Medicine News, Johns Hopkins Medicine, Lean Six Sigma, limited capacity, Maryland, Model, NCCN clinical guidelines, Nurse Practitioners, Nurses, nurses and therapists, Organization, Patients, Performance, pharmacists, Physical Assistants, Physician, PrimeASCENT, Production, Quality, Reduce demand, Referring, Safety, scheduling, Smooth demand, Southwest Airlines, Standardization of care processes, Strategy, ThedaCare, Therapists, time-outs, Tool, Treatment Options, University of Pennsylvania, Virginia Mason Medical Center, Volkswagen As A Model For Cancer Care?, Volkswagon
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Friday, June 10th, 2011
Last week, I talked about the lack of transparency with respect to the quality and safety of cancer programs. This lack of transparency, combined with dry and technical jargon on the web sites of many cancer programs, makes it nearly impossible for anxious patients and their referring physicians to determine where they will get the best care for their cancer. Nor is the sparse information doing anything to build trust and confidence in increasingly discerning patients. They can learn much more and much faster about cancer programs when they go to US News & World Report, as opposed to researching nearby cancer programs.
So, how should you talk about your cancer program? Well, there are a few key things that will inspire patients to be treated at your cancer program. The critical success factors in this decision process are credibility, confidence and trust. These, in turn, are based on reputation, proven outcomes, experience, depth and breadth of treatment options and the ability to effectively treat complications as well as provide physical and mental comfort during and after treatment. Cancer is, after all, a deadly disease and most cancer patients will experience their diagnosis as a death sentence, or something close to it. My teenage daughter was twice diagnosed with acute lymphocytic leukemia, first as a toddler and a second time when she was a teenager, so I speak from personal experience.
Recently, some hospitals and cancer programs started to tell a better story about themselves. The Cancer Institute at St. Joseph’s Medical Center in Baltimore promotes “No More Sleepless NightsSM”, which is a fast track for women with a lump in their breast or with an abnormal Mammogram. In addition, the Cancer Institute has a motto that is as compelling as it is simple: “One Team. One Plan, One Place”. What makes these two concepts so compelling is that they are easily understood, valued by patients and easy to remember. Both concepts have a high degree of “stickiness” in the minds of the targeted audiences and will instill confidence in the treatment process.
Cleveland Clinic Foundation’s Taussig Cancer Institute publishes an annual Outcomes Book with detailed information about patient volumes, procedure volumes, survival rates, process indicators, etc. for the major types of cancer.
Christiana Care Health System in Delaware publishes an attractive Annual Quality and Patient Safety Report that summarizes specific quality and patient safety improvement initiatives that are being pursued across all medical specialties, along with the results achieved.
Finally, I am sharing this video clip with you that demonstrates how to present a technical – and boring – topic and discuss it in such an exciting and insightful manner that it is likely to be remembered by a large audience for a long time. Enjoy Hans Rossling’s health trends summary “200 Countries. 200 Years. 4 Minutes. The Joy Of Stats”!
So what are the take aways from all of this? Well, to stand out as a cancer program, you need to combine the three examples I shared with you to create a meaningful picture of why your cancer program is as good or better than other cancer programs in your region, specifically:
1. Create a message that summarizes the excellence – and differentiating approach – of your cancer program in a way that is valued by patients, is easy to understand and is memorable similar to what St. Joseph’s Medical Center did.
2. Support your claims of excellence with credible facts, using the examples of the Cleveland Clinic and Christiana Care Health System.
3. Communicate your excellence in cancer care in an inspiring and visually appealing way, using Hans Rossling’s approach as a creative example.
This approach will help you demonstrate in a credible manner that you are truly focused on the patient. Finally, patients will feel confident in and, hopefully, be reassured by your cancer program if you show the positive trend in cancer care excellence in terms that patients can relate to. Presenting this information in a visually compelling manner, as Hans Rossling did, will make it even more powerful.
I hope you are as inspired by these examples as I am. Call us for a free consultation to help you craft your outcomes message to your physician and patient community.
Yours in Oncology Excellence,
Paul Schilstra
President
Tags: Annual Quality and Patient Safety Report, best care, Cancer, Cancer care, Cancer center Maryland, Cancer Maryland, Cancer program, Cancer Program Maryland, cancer programs, Complications, deadly disease, Death Sentence, diagnosis, Efficiency, Efficient, Example, Examples, Experience, Health Affairs, Health System, Healthcare, High-Performance, Hospital, hospitals, Improvement, Input, Leukemia, Maryland, Mental Comfort, Model, Mother, Mother Nature, Nature, Navy, Newsweek, Nuclear, Organization, patient volumes, Patients, Performance, Physical comfort, Physician, PrimeASCENT, procedure volumes, process indicators, Production, Quality, Refer, Referring, referring physicians, Report, Reputation, Safety, Safety At Your Cancer Program, success factors, survival rates, Tool, Toyota, Transparency, Treating, Treatment, Treatment Options, U.S., Volkswagen As A Model For Cancer Care?, Volkswagon
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Friday, June 3rd, 2011
Last week, Paul O’Neill, former U.S. Treasury Secretary and former CEO of Alcoa, spoke at the annual National Patient Safety Foundation Congress. O’Neill is a member of the Lucian Leape Institute and previously led Alcoa’s transformation to becoming the safest large manufacturers in the US with a risk of an on-the-job injury that is about 5% of the national rate!
He said that “organizations are habitually excellent or they’re not”. O’Neill also said that hospitals should post rates of nosocomial infections, patient falls, medication errors and employee injuries on the Internet so that everyone can see them, and he thinks that they should to do it every day. O’Neill said, “Let’s bring some energy to this”.
Many cancer programs are already in the process of improving the quality and safety of their care but you would not know it from looking at their web sites. Few cancer programs tell a compelling story about the quality and safety of their care – along with real and measurable reasons to believe – that help instill confidence and trust among patients, payers, employers and referring physicians.
Most cancer programs provide very little information about their treatment and support capabilities and almost nothing about quality and safety. When they do share information about their services, it tends be technical, sometimes intimidating, dry, confusing and fragmented across web pages and pdf documents. It is very much up to the patient to become Sherlock Holmes and pursue labor-intensive detective work to determine whether that cancer program really is the best option for his or her cancer.
Imagine a cancer program, showing newly diagnosed cancer patients and their loved ones, its progress in improving the quality, safety and efficiency of its care, and doing it with passion, insight and justified pride. The need for it is only increasing as the Centers for Medicare and Medicaid Services, the American College of Surgeons’ Commission on Cancer and others require measurable improvements in quality, safety and efficiency. In addition, organizations such as US News & World Report and HealthGrades continue to fill the information void and are able to analyze and publicly report on the quality, safety and efficiency of healthcare. It would be a shame if a cancer program’s good news continues to get lost among dry, uninformative and uninspiring web pages and brochures.
What do you think about increased transparency of cancer care? Is it now time for cancer programs to reveal compelling and differentiating stories about their excellence?
Yours in oncology excellence,
Paul Schilstra
Tags: Alcoa, Cancer, Cancer care, Cancer center Maryland, Cancer Maryland, Cancer program, cancer programs, Care, Centers for Medicare, Efficiency, efficiency of healthcare, Efficient, Ellicott City, Example, Examples, Health Affairs, Healthcare, High-Performance, Hospital, hospitals, Improvement, Input, Lucian Leape Institute, Maryland, Medicaid Services, medication errors, Model, Mother, Mother Nature, National Patient Safety Foundation Congress, Nature, Navy, Newsweek, nosocomial infections, Nuclear, Organization, patient falls, Patients, Performance, Physician, PrimeASCENT, Production, Quality, quality and safety of their care, Quality of healthcare, Refer, Referring, Safety, Safety of healthcare, Sherlock Holmes, the American College of Surgeons’ Commission on Cancer, Tool, Transparency, Treatment, U.S., U.S. Treasury, Volkswagen As A Model For Cancer Care?
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Wednesday, May 18th, 2011
Yesterday, I listened to Terry Gross’ interview with New York Times’ reporter Walt Bogdanich during NPR’s Fresh Air. Walt wrote a series of articles in the New York Times during 2009 about over-radiation during diagnostic and therapeutic procedures at various institutions. Some of these incidents led to serious injuries and the death of cancer patients. Many more patients may have been injured but health problems may not show for many years, since over-radiation may take a long time to cause serious damage to a human body.
Walt’s analysis indicated that few regulations and, more importantly, few safeguards are in place to prevent these errors from occurring. In addition, radiation-emitting technology for diagnostic and therapeutic procedures has become increasingly complex, while training of clinicians by vendors on the proper operation of these medical devices may be inadequate.
Three things struck me most about Walt’s observations during his interview with Terry. First, these errors continued even after the New York Times published Walt’s articles! Second, regulations and licensing requirements vary greatly from state to state. Third, legislative proposals to improve the safety of radiation nation-wide are languishing in Congress, despite an initial flurry of Congressional hearings and activities following the publication of Walt’s articles in the New York Times in 2009, and despite initiatives by ASTRO, AAPM and ACR to improve the safety of radiation in healthcare.
Walt concluded his interview by advising cancer patients to ask their oncologist(s) about accreditation, about the number of procedures they have done, and whether they and their staff are licensed and properly trained. He also said that he recommends that patients go to “top flight” and accredited institutions for cancer treatment. This should serve as a “wake-up call” to cancer programs and cancer centers offering radiation therapy. Walt has made many public appearances since his articles were published, and he continues to openly caution patients about where to seek their treatment.
Interestingly, all is not well in Medical Oncology either. During the open NCCN meeting on Patient Safety and Quality in Cancer Care last February, 2011, presenters commented that medication safety was still a significant challenge despite major initiatives during the last decade.
I will add my own, albeit unscientific, observations. During my research of many cancer programs around the country, I learned the following.
As the Greek philosopher Aristotle once said, nature hates a vacuum. In this era of value-based healthcare, social networking, the internet, blogs and savvy healthcare marketing, any information vacuum may lead patients and referring physicians to assume that a particular cancer program is not accredited and not working hard to improve outcomes, quality and safety.
Cancer programs stand to gain a great deal from accreditation and improving outcomes, quality, safety and efficiency, from greater transparency and by advertising their accomplishments effectively to their communities (see also my blog “Volkswagen As A Model For Cancer Care?”, dated April 8, 2011).
So has cancer care become safer since 2009? Probably, but only the leading academic and community-based cancer programs communicate their efforts and accomplishments to the general public. Unfortunately, few cancer programs are publicly demonstrating their efforts to offer high quality, safe and efficient care.
What initiatives is your cancer program pursuing to improve outcomes, quality, safety and efficiency? How well is your cancer program communicating its commitment to and achievement of high quality and safe care to the general public?
If you have any questions, contact primeASCENT by calling 410-444-6024 or click here today!
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Monday, May 9th, 2011
I frequently observe on-line discussions between cancer centers about the capacity required to meet the demand for cancer care. These discussions range from questions about productivity ratios, e.g., nursing staff to patient ratios, to best practices regarding patient scheduling.
Colleagues usually share their insights and experiences readily, while representatives from professional organizations often also provide helpful information or links to relevant articles that help cancer centers to best meet the demand for services while improving productivity. There are also commercially available sources that offer best practices regarding required cancer program capacity and productivity in terms of rooms, staffing, chairs, etc.
None of this is wrong, of course, and benchmarks can be quite useful. Benchmarking of processes or productivity is useful when creating a cancer program from scratch, but only as a starting point and a rough target. For an existing cancer center, copying someone else’s process, organizational structure or productivity ratios without understanding how AND why it might actually improve the quality, safety and efficiency can potentially take you down the slippery road toward making matters worse as key assumptions may prove to be wrong.
For example, cancer center A uses a staffing ratio of one nurse for every two patients treated simultaneously and is looking to boost productivity to reduce costs. Cancer center B uses a ratio of one nurse to four patients who are treated simultaneously. It may be tempting for cancer center A to adopt the same nurse staffing ratio that cancer center B uses but it should only do so after some rigorous due diligence to assess the potential impact on the quality, safety and efficiency of the cancer program. After all, cancer center B may very well be treating a much less complex and less resource-intensive patient population than cancer center A. In addition, cancer center B’s outcomes and safety record may very well be less than those of cancer center A.
Before using benchmarks, a cancer program should first assess its own performance with respect to quality, safety and efficiency through a quantitative baseline. In addition, it should develop a good understanding of the current issues and how they affect the quality, safety and efficiency of patient care. There may be a number of root causes that result in avoidable delays, errors, costs and less than optimal outcomes.
For example, cancer center A should first review all its key processes from scheduling through discharge to determine how to best reduce costs. It should also assess the case mix and fluctuating patient volumes by time of day and day of the week in relation to available staff, rooms and chairs, etc. Finally, it needs to assess how all these factors affect outcomes, safety and costs.
Next, the cancer program leadership needs to define what the objective is for improvement. Is it quality, or safety or reducing costs? Defining the central goal terms for improvement in plain English is essential to identifying potential solutions that have been successfully tried and tested by others. Interestingly, the proper use of Lean Six Sigma should lead to improving quality, safety and efficiency. For example, Toyota’s current goal is to shorten the time between receiving a customer order and receiving payment from the customer for the car. It can’t get much clearer than that. Through its relentless and continued focus on eliminating waste, Toyota has been able to shorten this time cycle continuously while managing cost and quality at the same time.
With the goal(s) clearly defined, potential solutions can be identified that have been successfully used at other cancer programs, e.g., a new process, an automated tool or better productivity ratios. The potential solutions should be studied carefully to thoroughly understand how and why it improved the quality, safety and efficiency of cancer care at the other facility. This is THE most important piece of information that is often lacking in sharing best practices. Copying a process, implementing new technology or applying a set of productivity ratios without understanding how and why this improved the quality, safety or efficiency of cancer care may ultimately result in making matters worse for both the cancer program and its patients.
Finally, a cancer program should measure the impact of improvement initiatives on the quality, safety and efficiency of its patient care processes on an ongoing basis, after the improvements have been successfully tested and implemented.
Each member of a cancer program team should embrace this journey of continuous learning and discovery about the cancer program’s processes. As each member learns and understands what will lead to successful improvements through his or her own personal experience, a culture of continuous improvement will emerge. Johns Hopkins
Medicine (1), ThedaCare (2), Toyota (3), the U.S. Navy’s Nuclear Program (4), and many other organizations have shown that this really does lead to a sustained culture of excellence.
I strongly recommend that you read about their journeys toward excellence and safety.
If you have any questions, contact PrimeASCENT by calling 410-444-6024 or click here today!
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References
1 Pronovost, Peter: “Safe Patients, Smart Hospitals”, Hudson Street Press, 2010
2 Toussaint, John and Gerard, Roger: “On the Mend”, Lean Enterprise Institute, 2010
3 Ohno, Taiichi: “Toyota Production System”, Productivity Press, 1988
4 National Nuclear Security Administration/Powering the Nuclear Navy at nnsa.energy.gov
Tags: Benchmarking, benchmarks, Better Performance, better productivity ratios, Cancer care, cancer centers, Cancer program, cancer program leadership, costs, delays, discharge, discovery, Efficiency, errors, goals clearly defined, implementing new technology, journey of continuous learning, Lean Six Sigma, Maryland, Medicine, Patients, Performance, potential solutions, PrimeASCENT, productivity, productivity ratio, Quality, reduce costs, Safety, ThedaCare, Toyota, U.S. Navy’s Nuclear Program
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Friday, April 15th, 2011
We all know that healthcare delivery systems in general, and cancer programs in particular, are faced with rapidly mounting challenges. ACOs and consolidation, value-based reimbursement that will lead to declining reimbursement, tighter regulation, rising demand due to a rapidly growing and aging population, and finally, expected and substantial physician and nurse shortages are enough to make any one’s head spin.
This situation can especially be challenging for smaller community hospital-based cancer programs, regardless of whether they are located in rural areas or in highly competitive, urban areas. Operating and capital budgets are often limited and access to capital continues to be quite a challenge for many.
There are plenty of options for addressing these challenges, to be sure, but when the purse is small, many solutions are simply too costly to pursue. So what are smaller community hospital-based cancer programs to do?
Toyota, in its early days, right after World War II and well before it was recognized as the “Machine That Changed The World” (1) may provide inspiration. When Toyota began to produce trucks and personal cars in 1947, it faced tremendous challenges. Japan lacked all the things American car manufacturers had: land, natural resources and capital. In contrast to its American counterparts, Toyota had to treat every ounce of raw material as if it was gold because it had to import these materials from other parts of the world at a high cost. In addition, it was impossible to produce cars in large batches, as the American car manufacturers did, simply because it did not have the physical space to park the cars before shipping them to the dealers.
Over a period of 30 years, Toyota began to turn its limitations into major competitive advantages. But it did not do so overnight. Neither were the concepts of Lean, Total Quality Management and Just In Time created instantaneously. These concepts gradually emerged as the key characteristics of what ultimately became known as the Toyota Production System. The Toyota team tenaciously resolved these daunting issues under the leadership of Taiichi Ohno (2).
The limitation of space was addressed by almost eliminating all inventories of raw materials, parts and finished cars. The limitation of space and the need to carefully use raw materials and parts were both further addressed by intensely focusing on improving quality and reducing waste. Over time, Toyota realized that waste was not just limited to quality but also to other aspects of the production process. As a result, Toyota’s focus changed gradually from dealing with formidable constraints to continuously shortening the time between a customer order and receiving payment from the customer. Thus, Lean was born.
What is truly amazing is that this process did not require enormous investments up front. Rather, Toyota’s constraints-based approach led to quality-improving and cost-saving innovations on a steady basis. The speed with which Toyota produced high-quality and low-cost cars became a strong competitive advantage and customers responded accordingly. During the 1980s, Toyota began to surpass the American car manufacturers, who had become complacent. Today, Toyota continues to be a leading example of an adaptive organization that never stops learning.
So here is the bottom line for smaller, community hospital-based cancer programs. Improving the quality, safety, efficiency and financial viability of these cancer programs should be viewed as a continuous journey of small and self-funding steps, and not as a radical, instantaneous and costly make-over. Each improvement initiative will lead to new insights and innovations, which in turn will lead them to the next step. Over time, each cancer program will create its own version of the Toyota Production System.
When will you begin your journey?
If you have any questions, contact PrimeASCENT by calling 410-444-6024 or click here today!
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1 – James P. Womack, Daniel T. Jones, and Daniel Roos: “The Machine That Changed The World”, Harper Perennial, 1991
2- Taiichi Ohno: “Toyota Production System”, Productivity Press, 1988
Tags: ACO, ACOs, America, American, Budget, Cancer, Cancer center Maryland, Cancer program, Car, Cars, Community, consolidation, Cost, Gold, Healthcare, High cost, Hospital, Japan, Journey, Low, Low-cost, Management, Maryland, Natural resources, Nurse, Nurse shortage, PrimeASCENT, Production, Production system, Program, Quality, Quality management, reimbursement, Solution, Solutions, System, Taiichi Ohno, Toyota, World War II, WWII
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Friday, April 8th, 2011
Today, researchers from the University of Utah and the Institute of Healthcare Improvement published their analysis of adverse events in hospitals in the April edition of Health Affairs. They found that adverse events occurred in about 30% of hospital admissions and the frequency of these events is ten times higher than previously thought. The researchers are concerned that the current use of patient safety indicators, combined with voluntary reporting, may result in misleading conclusions.
This study underscores that there still is so much we do not yet know about healthcare delivery processes in general. This certainly is also true with respect to the quality, safety and efficiency of cancer programs, which are among the most complex of healthcare delivery processes. An article published by Newsweek in October, 2009, reported the wide disparities in cancer diagnosis and treatments, as well as the lack of transparency with respect to quality.
There are numerous logistical and philosophical challenges standing in the way of more transparent cancer care. In addition, few physicians and cancer program administrators are comfortable sharing quality and safety data with the general public as data can be easily misunderstood.
Unfortunately, the absence of meaningful information about the quality, safety and efficiency makes it difficult for cancer programs to improve their care delivery processes. It also makes it much harder for patients, payers and their referring physicians to determine which cancer program delivers the best cancer care. In the absence of hard facts, subjective perceptions inevitably fill the void, right or wrong. After all, Mother Nature dislikes a vacuum.
Yet, there are plenty of great quality, safety and efficiency examples in other industries that we should learn from. Well-known examples of high-performance organizations and industries include the famous Toyota Production System, the airline industry and the U.S. Navy Nuclear Program. And then there is the Volkswagen model of transparency. Imagine transparent cancer care like this! By opening up, problems become visible much sooner and clinical teams, with input from patients, can address them more readily. Being great at treating cancer is very important, but being great at learning to continuously improve the delivery of cancer care is paramount to increasing patient survival and improving quality of life. Volkswagen shows us that it can also be a cool and powerful marketing tool. Patients, referring physicians and payers would no doubt agree.
But would it work for your cancer program?
If you have any questions, contact PrimeASCENT by calling 410-444-6024 or click here today!
Tags: Cancer, Cancer care, Cancer Maryland, Care, Efficiency, Efficient, Ellicott City, Example, Examples, Health Affairs, Healthcare, High-Performance, Improvement, Input, Marketing, Model, Mother, Mother Nature, Nature, Navy, Newsweek, Nuclear, Organization, Patients, Performance, Physician, PrimeASCENT, Production, Quality, Refer, Referring, Report, Safety, Tool, Toyota, Transparency, Treating, Treatment, U.S., Volkswagen As A Model For Cancer Care?, Volkswagon, Well-known
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